Complex Arterial Reconstruction for Pancreas Transplantation in Recipients With Advanced Arteriosclerosis

Abstract

We read with interest the article by Fridell et al. (1). They eloquently described techniques for tackling vascular disease in pancreas transplant recipients. We agree that the measures to reduce technical complications in these recipients with arterial disease should be undertaken before the organs are taken out of ice, to reduce the warm ischemia. However, we have not used any of the methods described by the authors and others (2–4). We approach the problem of diseased recipient vessels by minimizing the number and duration of clamps used on the arterial tree by constructing a single inflow arterial conduit for both organs. We would like to share our techniques in dealing with recipient vessel disease from our series of 150 pancreas transplants. Palpation of the recipient's iliac vessels at the start of the operation helps us determine the nature of revascularization needed. We routinely procure the ascending arch of the donor's aorta with the brachiocephalic and left innominate branches from all multi-organ donors. In a series of 150 patients we had to resort to two complex reconstructions. Case 1 (Fig. 1A): A 55-year-old Caucasian man undergoing simultaneous kidney–pancreas transplantation had severe aortic calcification with right common iliac artery stenosis identified on preoperative angiography, which was confirmed on laparotomy. The left common iliac artery and external iliac artery were relatively disease-free. The left external iliac artery was used to provide the in-flow. Back-table preparation was as follows: the donor brachiocephalic trunk (BC) was used as a Y graft, one limb was anastomosed end-end to the graft renal artery; the other limb was attached end-end to the donor common carotid extension graft, which was in turn anastomosed end-end to the common limb of the iliac Y graft. The arterial inflow to the composite graft was obtained from the left EIA with standard venous drainage for both grafts.FIGURE 1.: Arterial reconstructions in pancreas transplantation. (A) Recipient with right common iliac artery (rCIA) stenosis. Donor brachiocephalic artery (BC) with common carotid artery (Car) used to provide arterial inflow to kidney and pancreas grafts. PV, graft portal vein; IVC, inferior vena cava; EIA, external iliac artery. (B) Recipient with severe aortoiliac calfication. Donor aortic arch graft implanted to provide inflow to both grafts. CIV, common iliac vein.Case 2 (Fig. 1B): a 67-year-old Caucasian man undergoing simultaneous kidney–pancreas was found to have a porcelain aorta and severe iliac calcification. Implantation was modified as follows: the donor's aortic arch with the brachiocephalic and left common carotid branches still attached, was implanted onto the right common iliac artery of the recipient, after endarterectomy of the recipient vessel. The free edge of the intima was tacked down. The vessels supplying the renal and the pancreatic grafts were anastomosed end-end to the brachiocephalic trunk and the common carotid branches respectively. Venous drainage of the pancreas was into the inferior vena cava and the renal vein was anastomosed to the left common iliac vein (Fig. 1B). Both patients recovered well without graft or vascular problems, and have excellent graft function at 11 and 6 months' follow up, respectively. We commend the technical aspects of the article by Fridell et al. and would also like to emphasize 2 points: careful planning of complex reconstructions helps avoid significant warm ischemic damage to the grafts at the time of implantation; second, the procurement of the brachiocephalic trunk and the aortic arch from the donor gives the recipient surgeon more options, should complex reconstructions become necessary. Anand S.R. Muthusamy Doruk E. Elker Debabrata Roy Isabel Quiroga Sanjay Sinha Anil C. Vaidya Oxford Transplant Centre Churchill Hospital Oxford, Oxfordshire, United Kingdom Peter J. Friend Oxford Transplant Centre Churchill Hospital Oxford, Oxfordshire, United Kingdom Nuffield Department of Surgery John Radcliffe Hospital Oxford, Oxfordshire, United Kingdom